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CLINICAL AND EPIDEMIOLOGICAL PECULIARITIES OF GASTRIC AND DUENAL LESIONS IN ELDERLY PATIENTS Pakirdinov A.S.1, Madazimov M.M.2, Mikhailevich I.E.3
1Pakirdinov Alisher Sayfitdinovich - Senior Lecturer; 2Madazimov Madaminjon Muminovich - Professor; 3Mikhailevich Ita Einikhovna - Associate Professor, DEPARTMENT OF OPTIONAL AND HOSPITAL SURGERY, ANDIJAN STATE MEDICAL INSTITUTE, ANDIJAN, REPUBLIC OF UZBEKISTAN
Abstract: an increase in the number of elderly patients with peptic ulcer disease and its complications, an increase in the structure of the disease of ulcers of large and gigantic sizes, long scarring periods pose a serious problem in choosing a method of treating the disease.
The features of functional and morphological changes in peptic ulcer disease, such as a decrease in secretory activity of the stomach, the predominance of atrophic forms of gastritis, pronounced microcirculation disorders in old age require further study and systematization to create a therapeutic and diagnostic algorithm and predict the course of the disease.
Keywords: peptic ulcer, clinical epidemiology, long-liver, age groups.
КЛИНИКО-ЭПИДЕМИОЛОГИЧЕСКИЕ ОСОБЕННОСТИ ЯЗВЕННЫХ ПОРАЖЕНИЙ ЖЕЛУДКА И ДВЕНАДЦАТИПЕРСТНОЙ КИШКИ БОЛЬНЫХ
ПОЖИЛОГО ВОЗРАСТА Пакирдинов А.С.1, Мадазимов М.М.2, Михайлевич И.Е.3
1Пакирдинов Алишер Сайфитдинович - старший преподаватель; 2Мадазимов Мадаминжон Муминович - профессор;
3Михайлевич Ита Ейниховна - доцент, кафедра факультативной и госпитальной хирургии, Андижанский государственный медицинский институт, г. Андижан, Республика Узбекистан
Аннотация: рост числа больных пожилого возраста с язвенной болезнью и ее осложнениями, увеличение в структуре заболевания язв больших и гигантских размеров, длительные сроки рубцевания представляют серьезную проблему в выборе метода лечения заболевания.
Особенности функциональных и морфологических изменений при язвенной болезни, такие как уменьшение секреторной активности желудка, преобладание атрофических форм гастрита, выраженные нарушения микроциркуляции в пожилом возрасте требуют дальнейшего изучения и систематизации для создания лечебно-диагностического алгоритма и прогнозирования течения заболевания. Ключевые слова: язвенная болезнь, клиническая эпидемиология, долгожитель, возрастные группы.
УДК 616.33-002.44:611-053.9
Relevance. Despite the improvement in the methods of examination and treatment of patients, ulcer duodenal ulcer among diseases of the digestive system continues to be one of the most frequent reasons for people seeking medical help. A similar situation is ascertained in all countries of the world. In particular, PU duodenal ulcer is detected in 6-10% of the world's population [2, 8]. In Western Europe, cases of duodenal ulcer disease are recorded annually in 0.1-0.3% of the population over 15 years of age [4]. In the United States, among 10% of adults, cases of gastric ulcer or duodenal ulcer are reported [5].
Peptic ulcer of the duodenum is a disease that mainly affects men. The ratio of men and women among patients with ulcer is from 2: 1 to 7: 1, and on average is 4: 1. Recently, there has been a clear convergence of these indicators due to the increase in cases of duodenal ulcer disease in women. In general, YAB KDP is found among people of all age groups. The sources of scientific literature provide information about the changes observed in the last 10-15 years in the structure of the incidence of peptic ulcer disease in the population, taking into account the age of patients [2]. The transformation of statistical data takes place in two directions. On the one hand, there is a "rejuvenation" of ulcer cases. On the other hand, there is an increase in the incidence of peptic ulcer disease, when the first manifestations of the disease are noted in people over 60 years of age and older. In old age, duodenal ulcers occur 1.7 times (and in old age - 3 times) less often than stomach ulcers [4].
According to V.T. Ivashkina, A.A. Sheptulina (2009), the proportion of the patient population over 60 years old is at least 10% of all patients with peptic ulcer disease. Taking into account the fact that the size of the contingent of the population, whose age exceeds 60 years, has been increasing on a global scale in recent years, it is obvious that
the incidence rates of Duodenal ulcer in patients of older age groups will also increase. This circumstance turns out to be an incentive for a special study of the problems of medical provision of elderly and senile patients with ulcer.
In elderly and senile patients, two variants of the development of duodenal ulcer are distinguished.
According to V.T. Ivashkina, A.A. Sheptulina (2009), the proportion of the patient population over 60 years old is at least 10% of all patients with peptic ulcer disease. Taking into account the fact that the size of the contingent of the population, whose age exceeds 60 years, has been increasing on a global scale in recent years, it is obvious that the incidence rates of Duodenal ulcer in patients of older age groups will also increase. This circumstance turns out to be an incentive for a special study of the problems of medical provision of elderly and senile patients with ulcer.
In elderly and senile patients, two variants of the development of duodenal ulcer are distinguished.
The second variant of the course of ulcer includes cases of the so-called "late" ulcer when the disease develops in patients who are already over 60 years old [3].
In the urban population, regardless of the age of patients, PU duodenal ulcer occurs, as a rule, more often than in residents of rural settlements [6].
Features of the clinical picture of duodenal ulcers in elderly and senile people are that this disease is often diagnosed against the background of other long-term diseases [1].Often, diseases associated with ulcer are accompanied by hypoxia, including the gastroduodenal mucosa [4]. In general, elderly and old age patients are characterized by polymorbidity. On average, there are up to 6 concurrent nosological forms per patient aged 60 and older.
It is difficult to objectively assess the effect of concomitant pathology on the course of ulcer, since until now there are no adequate systems for assessing the severity of the course of concomitant diseases, as is customary in cases of critical conditions [2]. This circumstance often leads to a late diagnosis of duodenal ulcer due to its atypical course, which contributes to an increase in the number of complications of the disease. In the structure of concomitant diseases of internal organs in elderly people, according to domestic authors, in almost 52% of cases a combination of peptic ulcer and ischemic heart disease is noted [8]. Peptic ulcer disease in people of older age groups with concomitant ischemic heart disease is often first manifested by a picture of gastrointestinal bleeding, which, as a rule, is recognized at a later date from its onset [5, 7].
Pathological changes in the vessels of the stomach and duodenum also play a significant role in the development of dystrophy and atrophy of the mucous membrane of these organs, contributing to the formation of ulcerative and erosive defects in them. In elderly people, peptic ulcer disease often develops against the background of atherosclerosis of the vessels of the digestive tract. The abuse of non-steroidal anti-inflammatory drugs by patients is of particular importance. The frequency of deaths from bleeding of ulcerative etiology in patients of older age groups in these cases can reach 20-40% [4, 9].
In 30% of cases in patients over 60 years of age, duodenal ulcer occurs with a distinct pain syndrome and high rates of acidity of gastric contents [2]. The clinical picture of duodenal ulcer in most elderly patients is erased and often the disease manifests itself with complications, the frequency of which increases from 31% (at the age of 6065 years) to 76% (at the age of 75-80 years) [3, 6].
Purpose of the study. Study of the clinical and epidemiological features of gastroduodenal ulcers in the population of centenarians and the development of an improved innovative prevention technology.
Materials and research methods. In the clinic of the AGMI Surgery No. 1 for 2019-1921, more than 56 patients with gastric ulcer and duodenal ulcer were examined and treated, of which 13.6% were elderly and senile patients.
For patients with ulcerative lesions of the gastrointestinal tract, a standard examination scheme was used, which included modern methods of instrumental and X-ray diagnostics. With endoscopy, a biopsy was performed from the ulcer and mucous membrane of the antrum and fundus of the stomach for morphological study of the material, and during X-ray examination - the relief of the mucosa and the motor-evacuation function of the stomach and duodenum.
Research results and discussion. The average age in the study group was 69 ± 5.7 years. Peptic ulcer disease with localization in the stomach was observed in 35.6% of patients, duodenal ulcers - 56.9% and acute ulcers - in 7.5%, and acute ulcers in the stomach were localized in 24-92.3% of patients. In accordance with A. Johnson's classification (1965), type I gastric ulcer was diagnosed in 55.5%, type II - 27%, and type III - 17.5% of patients.
According to the acid-peptic theory, ulceration is based primarily on an imbalance between the state of the protective factors that determine the resistance of the gastroduodenal mucosa and the factors of aggression.
In old age, the aggressive role of gastroduodenal motility disorders increases. Duodenogastric reflux (DGR) is one of the manifestations of these factors of aggression. There are two forms of GHR: physiological, which is an additional factor in the neutralization of hydrochloric acid, and pathological, which activates pepsinogen even in the absence of hydrochloric acid. In old age, pathological GHD occurs in 45% of patients.
When bile acids enter the stomach lumen under conditions of delayed reverse evacuation, especially during hungry or interdigestive periods, the phenomenon of reverse diffusion of hydrogen ions is realized, which plays an important role in ulceration. Probably, this can explain the increase in the number of combined ulcers in the stomach and duodenum in old age.
Indicators of gastric secretory activity according to pH-metric data differ among the young and the elderly. The group of "healthy" patients included patients who did not have complaints characteristic of peptic ulcer disease, anamnesis and ulcerative lesions with EGDS with morphological examination of the mucosa. The young age group also included patients 20-40 years old with peptic ulcer disease or non-ulcer dyspepsia.
The obtained results showed that in elderly patients the index of aggression and the intensity of acid production is significantly lower than at a young age, and the protective function of the antrum is more impaired, as evidenced by the value of the ratio index - it exceeds 1, while normally it is 0.3 -0.7 units.
Interesting results were obtained when comparing the morphological data of the study of the gastric mucosa. In the group of relatively healthy elderly patients, the severity of active gastritis is much lower, atrophy of the mucous membrane of the antrum of the stomach predominates, and intestinal metaplasia is often observed. Infection HP is not more than 10%.
With peptic ulcer disease in old age, active gastritis is observed in more than half of the cases, however, with duodenal ulcer, atrophy and intestinal metaplasia are absent, and Hp infection occurs in more than half of patients. In case of gastric ulcer, the phenomena of atrophy and intestinal metaplasia in the antrum prevail, and Hp infection was detected in 13.5% of cases. The presence of atrophy in the fundus of the stomach (in 37-40% of our patients) indicates the failure of protective factors, is a prognostically unfavorable sign and occurs in 75-80% of patients with giant and difficult-to-scar ulcers.
Output. Thus, in old and young age, duodenal ulcer is characterized by similar morphological changes, which indicates the preserved functional activity of the stomach. With gastric ulcer in the elderly, functional and morphological parameters are reduced, which can lead to malignancy.
After analyzing the results obtained, it is possible to single out the criteria for predicting the course of peptic ulcer disease in old age. We divided them into factors of aggression, factors of inadequate protection of the mucous membrane and provoking factors.
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